Publications
APS Bulletin • Volume 16, Number 3, Fall 2006
Resource Reviews
John D. Loeser, MD, Department Editor
The Paths of Pain, 1975–2005
Reviewed by Peter R. Wilson, MD
Harold Merskey, John D. Loeser, and Ronald Dubner (Eds.), Seattle, IASP Press, 2005. Hard cover, 549 pages, ISBN 0-931092-56-6, $65 nonmembers, $55 IASP members.
The dust jacket summarizes this volume—the most famous bridges in the two cities of relevance: the Ponte Veccio in Florence where the neonatal IASP met in 1975 for the first time, and the Sydney Harbour Bridge in the city of the mature 11th World Congress in 2005. The contents, though, are just as symbolic: they summarize the history, present state, and future directions of pain research and patient care. It is a worthy addition to any personal or institutional library.
Thirty-five chapters written by 49 pioneers of the paths of pain review all the significant progress that has been made since the journal Pain was first published in 1975. All of these authors have been widely published in that journal and many others. It is impossible to imagine any pain researcher, practitioner, or patient whose life has not been positively affected and significantly improved by these individuals, in person, by their students and protégés, and by their writings.
The subjects of each chapter were carefully chosen by committee to give a broad summary of the events of pain research and practice over the last 30 years, and ideas for future directions. The volume serves its purpose in not only showing the extraordinary accumulation of knowledge about pain during that time but also showing clearly how much more needs to be done.
Although the chapters are not formally arranged in sections, the first three chapters address historical aspects of pain concepts and of the IASP itself. Three later chapters review the historical perspective of migraine pathophysiology theories, therapeutic electrical neurostimulation, and of pain taxonomy. Five chapters review the molecular basis of receptors, genetics of pain, spinal cord and central nociceptive pathways, and descending modulation of nociception. Other basic-science topics include the role of glia in pain, pharmacology of inflammatory pain, opioid and nonopioid analgesia, and clinical implications of animal models. Measurement of pain is covered in chapters on sensory quantification, clinical pain measurement, and clinical brain imaging. Specific clinical syndromes are covered in chapters on orofacial pain, central pain, musculoskeletal pain, neck and low back pain, and rheumatological/soft-tissue pain. There are also chapters addressing the epidemiology of pain, psychological and psychiatric issues, and pain in children. Therapies of pain are discussed under the general headings of neural blockade and neuromodulation, opioids, topical agents, and multidisciplinary management. The final chapter summarizes a possible future of pain therapies.
It is not possible in the space available to review each chapter in detail; I found them mostly informative, provocative, and very well written. Zimmerman condenses 500 years of concepts of pain into a 20-page first chapter, an impossible task that he accomplishes with the excellent use of selected and generally available references. The pivotal theory in pain research—gate theory—is critically examined by Cervero. The problems of the theory are discussed, but he admits that it has contributed to a considerable surge in pain research. He includes his nearly-as-famous diagram of the model to explain touch-evoked pain in normal skin and skin after an injury.
Willis takes a different approach in his review of advances in knowledge of the physiology and anatomy of the spinal-cord pain system. He covers primary afferent nociceptors, the tract of Lissauer and the dorsal horn, the gate control theory itself, nociceptive spinal cord neurones and tracts, and other ascending tracts and their central connections. He is the director of the laboratory in which many, if not most, of the new data were gathered, and presents a comprehensive and unbiased overview. Three of the most challenging areas of pain research, both basic and translational, are reviewed by Dubner. He identifies sensory coding, descending modulation, and activity-dependent neuronal plasticity as areas in which great strides have been made, but where there are still many questions.
The chapter of greatest interest to me is Yaksh’s on opiate analgesia over the last 40 years. I had the privilege of working in his and Fred Kerr’s laboratory in the early days, and recognized that they complemented each other perfectly. Kerr had an encyclopedic knowledge of neuroanatomy at all levels; Yaksh understood neurochemistry to a degree that has become well apparent in his 500+ peer-reviewed papers since those days.
Gracely provides an interesting perspective on the development of the McGill Pain Questionnaire and the use of signal detection theory in evaluation of pain sensations. He also refers to several vigorous debates in the literature about the constituents of the pain sensation. The explosive growth of real-time brain imaging is reviewed by Bushnell. She is one of the pioneers in this field, and is able to place studies of abnormal pain processing, and pharmacologic and non-pharmacologic analgesia in perspective. She makes a plea for thoughtful integration of all information, basic and clinical, when testing hypotheses with these new technologies.
Chapters of particular and relevant clinical interest include those on neck pain (Bogduk), low back pain (Waddell), fibromyalgia (Moldofsky and Merskey), and pediatric pain (McGrath). Neuromodulation and neural blockade are addressed by Murphy and Cousins, opioid therapy by Moulin, and multidisciplinary pain management by Loeser. A final, challenging chapter by Basbaum is divided into the sections: something old, something new, something borrowed, and something blue. The “old” includes revisiting opioids and NSAIDs; the “new” has lots of targets, but not enough arrows (for example, the NMDA receptor and various ion channels).
This volume is an absorbing overview of all aspects of pain over the last 30 years. The areas covered are reviewed very thoughtfully. There are some omissions, but they are unavoidable in a volume such as this. These would include the development of ethical, political, and legal standards for pain management, societal attitudes to pain in developed and underdeveloped countries, and the emergence of “special” and disadvantaged groups with pain—the elderly, poor, and minority patients over the same 30 years. IASP members have played a pivotal role in all these areas and perhaps should be recognized.
Dr. Wilson is Professor of Pain Medicine and Anesthesiology at Mayo Clinic College of Medicine, Rochester, MN.
Dr. Loeser is Professor of Neurological Surgery and Anesthesiology at the University of Washington, Seattle.